Episode 52Advocating for your Health and Working with Your Doctor:Interview with John Limansky

Have you struggled to get your doctor on board with your desire to use food as medicine to heal your own body? Having trouble bridging the gap between conventional and functional medicine on your journey to optimal health? Tune in to hear Ali and Becki interview Dr. John Limansky, conventional doctor turned “recovering physician” about the ways that individuals can be their own best health advocate, approaches for using a ketogenic diet to heal your body and his cutting edge work in the realm of biohacking!

In this episode, Ali and Becki interview Dr. John Limansky, a Board Certified Physician in Internal Medicine and discuss his journey from being a hospitalist to using a ketogenic approach clinically. Dr. Limansky combines modern medicine techniques with nutritional ketosis to help clients reverse metabolic diseases, improve cellular health and lose real fat pounds. He also uses biohacking techniques as part of a virtual health system to optimize human performance for athletes and high functioning individuals. Learn about labs to ask your doctor for, whether using a ketogenic approach or not, tools and supplements for best outcomes with ketosis and hear his take on some of the backlash that the ketogenic diet has gotten from mainstream medicine practitioners.

Welcome to the Naturally Nourished podcast which delivers cutting edge food is medicine solutions for optimal health. Ali Miller is a nutrition expert sought out by the media in America’s top medical institutes for her revolutionary function medicine interventions. From disease treatment to prevention every episode will empower you with ways to put yourself back in control of your health. Please note these topics are for educational purposes only. Now welcome integrative dietitian Ali Miller and her co-host Becki Yoo.

A: Welcome back to the naturally nourished podcast this is Ali Miller and I’m here with Becki Yoo.

B: Hey guys.

A: And y’all are joining us for episode 52 advocating for your health and working with your doctor featuring a guest doctor John Limansky, the Keto-Doc.

B: We thought this episode would be really helpful for our listeners because we’re always hearing people asking for doctor referrals or struggling to work with their doctors and get them onboard with using food is medicine and especially with using ketosis as medicine.

A: Absolutely, so I met Dr. John Limansky at KetoCon I guess a couple weeks back now and we were both on a panel talking about neurological health and cancer and we had some great conversations about how to work with you doctor and his transition from more of a mainstream conventional practice in Mississippi and now doing a more boutique practice out in California and how he is able to use the ketogenic diet in his clinical practice.

B: Awesome so this episode will really focus on his story and his transition, what he’s seen clinically and then a whole bunch about the ketogenic diet and the outcomes that he’s seen with his patients

A: Yes, we’ve talked about labs that are recommended to assess, best way to measure ketone output. We problem solved and gave him a couple of I think challenging questions, so we hope you all enjoy we had a lot of fun interviewing him, and we hope you have as much fun listening. So, Becki, let’s give listeners a little bit of background on John Limansky prior to bringing him onto the show today

B: John Limansky, MD is a board certified physician in internal medicine. He combines modern medicine techniques with nutritional ketosis to help clients reverse metabolic diseases, improve cellular health and lose real pounds of fat. He also uses biohacking techniques as part of a virtual health system to optimize human performance of athletes and high function individuals. For more information he’s available via email at info@johnlimanskymd.com or johnlimanskymd.com.

A: So we’ll be sure to put both of those, the email and his website in our show links. But without further or do let’s bring John on.

B: Hi Dr. John, we are so glad to have you today on the show. So we’re just gonna jump right in and I know you and Ali met on a panel at keto con. The panel was on neurological health and cancer and I wasn’t there but I got to watch it afterwards. And I also heard you call yourself a recovering physician and listen to your lecture on keto and biohacking. So let’s just get started and talk a little bit about your use of ketosis in clinical practice and how that varies from your training and early clinical experience.

J: Ok yeah hey guys great to be on the show. Long time listener, I really like the content that you guys put out, so umm, yeah, I’m an internal medicine physician and I worked in a hospital setting for quite a while. I realized that to really make change in the health of America and individuals it’s important to focus on preventative medicine and really using nutrition, biohacking to optimize that. Especially with ketosis or ketogenic lifestyle, there’s so many advantages from a health perspective that I used it quite a bit with my clients to give them a baseline. So the way I look at it is, you cannot do nutrition in a bubble, you can’t do it by itself, you have to address other components of somebody’s life including stress, sleep, exercise, even stuff like gratuity.

But the fundamental baseline has to be through nutrition. You know if you do all those other things and you do not address nutrition, it’s really not gonna be successful. And so ketosis or ketogenic lifestyle is really about going back to the root of what we’ve been doing like ancestrally in terms of our health and nutrition. You know if you think back to our ancestors what would they do, they would eat a large meal and then store some of that as fat to be used for you know periods of famine when they basically couldn’t catch an animal or eat. Problem with modern society is that we always are eating, we always have that switch on and so part of that has to do with we no longer have signals being sent that give us this idea that we are full and so we keep eating. If you switch over to nutritional ketosis, then that dramatically influences that you start having signals that tell you you’re full, and obviously from a cellular level you get tremendous benefits. So, I really use it as my baseline and then build off of it.

A: And can you define for listeners this concept of biohacking, I think we actually have not used the term in our podcast at all yet.

J: Sure

A: It might sound a little bit you know strange, what are you defining biohacking as?

J: Yeah so biohacking is becoming trendy, it sounds bigger than it is

A: Right

J: But really what it is is, you’re trying to use all these different modalities, so using methods like sleep, trying to train yourself to sleep better and you can use electronic devices and nutritional changes like the ketogenic lifestyle to really improve everything at a cellular level. So you’ll hear a lot of things on social media or in the news about mitochondrial health, and that’s really what biohacking tries to get to it’s this idea of using everything in your environment either to improve your life or negatively affect it. And so as a society, we are very stimulated we always have lights on, we always have tvs on, we are always in our phone. All these things can negatively affect our health, especially our autonomic system, so we try to use different techniques to really try kind of balance ourselves again. Probably the best biohacker or the original biohackers are gonna be the yogis. So they would go do yoga or monks would go up in the hills, meditate. What they were trying to do is trying to recenter themselves. So we are essentially trying to be mini yogis without actually having to go to a mountain and meditate for 5 years on end

A: And that’s interesting because often I think nowadays with the concept of biohacking it seems we are trying to out-technology technology, versus just give in to the organica. I love that comparison of yogis of being original biohackers because it doesn’t always take another layer of an ad on of a blue blocker glasses you’re your computer you’re using late at night. Maybe just shut it down man. So I think that’s an interesting perspective for sure.

J: No just one little side note you know you’ll see guys probably the ones pushing that kind of technology Ben Greenfield and there is something to be said about you know going to nature or just meditating for 5 minutes. Not having to add all these cool technologies to really maximize the benefits and its important to know because I think a lot of people here, you know biohacking they see these fancy tools, and they think well that’s gonna cost me 50,000 dollars.

A: Sure.

J: I can’t do it. Well in reality you can, all you need is a quiet space 5 minutes meditation and your essentially biohacking yourself.

A: And likely it’s a layering effect as well, you know so where you used the term biohacking, Becki and myself use the term functional medicine in a very similar way as far as addressing this root cause, using technology and information to address these underlying mechanisms of imbalance and foundationally speaking be it that the ketogenic diet or a high fat, low carbohydrate diet could be optimal foundation, but then there’s these layers and additional add ons that may be necessary as far as nutritional supplementation and tools and things like that. So I think it’s interesting and that’s where we get really individualized with best patient outcomes.

J: Exactly.

A: So let’s talk about your transition from practicing as an internist or were you an emergency doc, emergency room doctor in Mississippi? Or tell me a little bit about where you were in Mississippi and what you’re doing now in California and maybe some of your biggest frustrations and the biggest decisions you’ve made career-wise.

J: Ok yeah so I did my medical residency in Colorado and after that I think most physicians go in medicine or nutritionists go in to nutrition for this idea that we really want to help people. I firmly believe that. At some point along the way that probably changes. I decided I wanted to go to the heart of this obesity epidemic and Mississippi is always top in the nation or number 2 so I decided I’m gonna go to Jackson, Mississippi. Went out there and spent about 5 years working not as an ER doc but as an internal medicine, as a hospitalist. So if you get admitted to the hospital I’m going to be the one taking care of you. And it was a very good experience in the sense that it was the hotbed of obesity, metabolic syndrome, all the things we are talking about on your podcast, and what was striking to me was how young people were. You’re talking people in their 20s, 30s having massive heart attacks, massive strokes, and I’m 39 so when I start seeing people younger than me having these massive diseases, it’s scary.

A: Sure.

J: And on top of it, I would see the same people over and over again. And so what would that tell me is a couple things: number 1 all of this is nutritionally derived, if somebody is in their 20s or 30s having massive heart attacks and there’s no real genetic predisposition what has changed in the environment that is affecting them? And so I started looking more into preventive medicine, functional medicine and I had been doing ketosis on myself for about 10-12 years so I started incorporating some of those techniques in patient care. I got a lot of pushback from it though. From the medical establishment and that was pretty striking so I decided to kind of change gears and do it on my own and I started a clinic kind of a virtual clinic in San Francisco to really address people’s health. Using biohacking, using ketosis to make sure that people don’t have to see me as a physician in the hospital for 50 years.

A: Sure.

J: And so you know I think I moved back to California just to be closer to family, but also most of a lot of the clients I’m working with live in Silicon Valley and so they wanted more of a direct 1 on 1 interaction with me.

A: Sure.

J: And so it made more sense logistically. And I think a lot of what we are talking about is really being driven now by Silicon Valley. They are starting to see the importance of health, not only for obviously cost benefits but also for performance. People are not getting sick, I haven’t been sick in 5 years, so my performance is a lot better. And so they’re starting to really see the benefits of it and I think it’s kind of the wave of the future especially for medicine.

B: Definitely, so let’s go back and get a little background on how you got into using the ketogenic diet both for yourself and your personal story and then applying that to your patients. And then within that question, if there was any kind of compelling either scientific study or big medical ah- ha moment you had, I’d like to hear about that too.

J: Sure. So, yeah, like I said, I’ve probably been doing ketogenic lifestyle for about 12 years, I actually used to be vegetarian prior to that and in medical school. I was young but I never really felt really good and I figured you know I’m just overworked and tired and studying all day. And there was “ah-ha” moment where after being vegetarian for about 4 years I got my lab work done, and it showed that I basically was prediabetic. I was on the verge of metabolic syndrome, and the interesting point was that my body fat percentage was probably about 10%. It wasn’t like I was obese, it was more this idea of where you’re skinny on the outside, but internally your metabolically damaged. And the idea was that “well I’m vegetarian, I’m eating healthy, I’m eating clean. Why is it affecting my body this way?” And on top of it, why am I not seeing weight gain, but I’m seeing metabolic damage? So that’s when I really started researching these different types of diets and fad diets and started reading more about ketogenic diet and at the time it wasn’t as big as it is now.

There wasn’t as much information out there. But fundamentally it made sense and I started reading back biochemistry. What people don’t really understand is that as a physician, we don’t get taught nutrition, we get taught biochemistry and biochemistry is basically how do things get broken down to create energy or how is the process in the body. It doesn’t really tie everything together in terms of the type of nutrition you eat, how does it affect your body positively or negatively? So you really, as a physician or anybody, you really have to read on your own. Nowadays anything that I really recommend to any of my clients, I do test on myself. So that allows me to keep up with all the information but also to see how things are gonna affect individuals and obviously it’s not gonna be 100% correlated but it’s gonna be pretty accurate in terms of like say I tell somebody to do a 5 day fast. How’s it going to feel? What are they going to experience? So that when they’re in it, I can tell them this is normal or this is abnormal.

A: Right and did you start first especially coming from the line of vegetarian diet which is so funny, I think so many of us do. It’s like the step one of the health journey and then the deficiency symptoms and then the metabolic syndrome and then the reset. Did you kind of transition first into more of a paleo approach or just incorporating animal proteins and then start looking at macros or did you delve right into ketogenic high fat and moderate protein. Kind of, what was the process, how many years for the vegetarian transition?

J: Right, so I’m pretty extreme so when I do something I do it 100%. And I just wanna say you brought something up pretty interesting. Most people I think do vegetarian for one of two reasons. It’s an ethical issue because of the way animals are treated. Or it’s I just want to be healthy, but inevitably you get nutritional deficiencies so for about a year you feel great but then it really catches up to you and you don’t feel very good. So for me, I went 100% straight into ketogenic lifestyle, almost 90% fat. So I kind of went a little more extreme because I wanted to affect my metabolic labs. I wanted to see a dramatic change. And then since then over the years since I’ve kind of normalized my insulin, all my other metabolic markers. Now I would say I do probably 70% fat but I’m very specific on the types of fat I consume. And I incorporate a lot more of carbohydrates in the sense of, I hate to use the word complex carbohydrates but vegetables, green vegetables. Because I think a lot of times you’ll see people who don’t really understand the ketogenic lifestyle, will say “ok I’m gonna just eat fat and I’m gonna avoid carbohydrates at all costs.”

A: Right.

J: Especially vegetables and you can actually get quite a bit of negative effects from doing that.

A: Sure and I actually I think that’s a great transition. So on that end, I know when we’re working with our clients and getting them keto-adapted often starts with doing more prolonged fasting to really drain out the glycogen stores. Doing more snacking versus meals as far as keeping vegetables little bit lower to really get the body fat adapted. But then it’s wild to see the allowance or variance that some people are able to incorporate. A tablespoon of pumpkin puree into a recipe. Or even starchy vegetables in moderation still stay full on ketogenic. So let’s talk about some of the pit falls, both in the perception of the medical field but also that you’ve seen clinically in an imbalanced ketogenic diet. Both ends of the sword if you would.

J: Sure. So from the medical community I would say that we still have to get away from this idea that fat is bad. So the low fat craze and the what I call “fat phobia” just won’t go away. And I think it’s gonna take the medical establishment quite a bit of time to really make that fundamental shift. I find it ironic that we keep saying that same thing as a medical establishment and we keep getting sicker and sicker individuals, but we don’t actually look at well why are people getting sicker. And obviously you can’t just say it’s fat or lack of fat in the diet that’s contributing to it but I do think it’s a significant factor. And so I think people have to understand the way the medical establishment work. Physicians have to follow guidelines that are put out by big societies like American Diabetes Association or the American Heart Association. They put out guidelines from everything, including nutrition, and if you’re not following those guidelines, you’re not necessarily practicing the standard of care for medicine.

And so that opens up physicians to a lot of liability and things like that. So it’s a very difficult situation to be in where you’re not promoting what they’re recommending but at the same time those guidelines are wrong. There’s a few physicians that are starting to push the envelope and saying we keep telling people the wrong thing. For instance if you’re type 2 diabetic and you follow the guidelines, you’re supposed to eat quite a bit of carbohydrates. It doesn’t make sense. Why would you feed someone who can’t handle sugar, which is essentially what carbohydrates are converted into, more sugar and tell them well take more insulin to combat the sugar. It just theoretically doesn’t make sense and yet that is what we tell people.

So I think, what I usually do with people in the medical community is give them information. So here’s what the research shows. For instance, with fat and saturated fat specifically, take the women’s health initiative. It will show you there’s increased morbidity with people on a low fat diet, so you get higher levels of cancer, higher levels of autoimmune disease. You die earlier, so there’s really no studies showing that eating a high fat diet are going to contribute to more metabolic diseases, it’s quite the opposite. And then on top of it, when you have clients and you check their labs and you put them on a ketogenic lifestyle, those labs improve. So why has it taken so long for the establishment to say ok well maybe there’s something wrong here, maybe we’re not telling people the right thing. And I think it’s going to take a while, I think it’s going take 20, 30 years to change.

A: And I think it also takes education on what labs we’re looking at as far as our greatest priorities. Are we looking at a shift in total LDL because we’ve also seen an improvement in total HDL and then we’ve seen a lipoprotein particle distribution improvement. And what’s the give and take in there and I think there’s a disconnect often in the allopathic or conventional model of, the getting gunshy, if you will. Of seeing short term transitions in lipids which often end up being favorable especially when we see things like homocysteine and CRP and other stronger correlators improving, and I think it’s often where we get a little bit of backwash if that total LDL goes up slightly for a period of time.

J: Right and that’s a very important point that you’ve just mentioned is that, and it’s very common that I get this. Where- so LDL, people understand it as the bad cholesterol. Well you can actually break down LDL into multiple different small types of particles and that’s what you’re referencing. And so some of these are actually good. So, APO B vs. APO A1 ratio is a much better test to measure the good vs bad. But a lot of internists don’t even know that test exists. So when you start a ketogenic lifestyle your LDL, which people think is the bad LDL will likely go up and that’s because you’re producing also very good small particles. The small particles will not damage endothelial cell lining. So they’re not gonna cause the atherosclerotic blocks that we associate with cardiogenic or cardiac disease. There actually gonna be protective.

So your LDL may go up, initially but the good types of LDL that you’re producing, and you want to produce are going up. And the bad types, which are gonna be very small particles which are gonna damage the lining of the blood vessels. Those are derived from refined carbohydrates. So you have to have a better understanding of the basic labs. You also mentioned the CRP or high res CRP, which is a marker of inflammation in the body. It’s not specific, it’s very sensitive, meaning it’s gonna tell you whether your body is inflamed or not. It’s not gonna tell you why your body’s inflamed. But, what’s important about it is that as you start implementing these different types of modality, like biohacking or nutrition, you’ll see that number go down. So you’ll know “ok, whatever I’m doing is causing decreased inflammation in my body” which is essentially what we’re all trying to accomplish. Because that means we’re healthier, we’re not gonna have metabolic dysfunction. And that’s really what we’re trying to address.

A: Absolutely, absolutely.

J: It’s very important to know the information.

B: So what about any negative impacts that you’ve seen or keto done wrong? Anything clinically you’ve seen manifest in patients labwork or otherwise?

J: Yeah so great question, I think it’s very important to have a very comprehensive baseline of studies of lab studies that you have done. Because keto is becoming quite popular these days. Because there’s a lot of information, a lot of misinformation. Anybody who’s done keto and lost 20 lbs. is all of the sudden an expert. Which is good in the sense that we’re getting more information out there and more people are becoming aware that it’s out there. But it’s also dangerous because a lot of times people will not understand the basic nutritional concepts or metabolic concepts like you or I would. So you know. Pretty good example is you’ll see vitamin deficiencies because people will do keto but they’ll do a very very high fat. One of my biggest pet peeves would be keto fast food.

A: Right.

J: So you see a lot of people talking about a ketogenic lifestyle. They’re going to McDonalds or they’re going to In-n-Out. They’re getting a hamburger but they’re not eating the bun, so that’s keto. Well it’s not keto because a couple things. Number 1, the cheese that they use is not cheese, its cheese prop. The meat that they use, is not the type of meat you want. So you have to delve in a little bit deeper. For instance the meat is gonna have been fed grains and those grains are high in omega-6, so those are gonna cause quite a bit of inflammation. The fats that they use to actually cook the meat is gonna be hydrogenated oils. So all those things bump up your inflammation, they’re gonna cause insulin resistance, possible leptin resistance, so you’re not gonna get the benefits. I think it’s important to understand what you’re trying to accomplish. So getting away from this concept of I’m doing keto just to lose weight. I think that’s 90% of people who are saying “I wanna lose 50 lbs. my friend has lost 50 lbs. on keto, so I’m gonna do keto to lose weight.” We have to get people away from this idea that weight is the end all be all goal. It’s not. Get your body healthy. Measure that by lab work, which you do really well. And then because of that you’re gonna lose whatever weight you want, it’s not even gonna be an issue. It’s a side effect of what you’re trying to accomplish.

A: Absolutely, and that’s that reference back when you were mentioning your own skinny fat per se right? When we’re experiencing this metabolic syndrome regardless of size, and especially I see, and again we’re big proponents of high fat-low carb diet, but I think it’s important to note. One of my big emphasis always when I’m lecturing on the concept is replacement is just as important as removal. You know? And that’s kind of one of my mantras or phrases because I think it requires such a fine tooth comb focus on the removal and really getting that rocking to get keto adapted. But then you have to find that 2.0 level of the replacement and the actual abundance foods, and the foods that have antioxidants and these disease fighting compounds. And how you can heal the body as a direct influencer on a nutritional level, beyond just the removal metabolic shifts that are occurring for sure.

J: Right, right that’s very important absolutely.

A: So let’s talk about some of those labs. So if we’re talking about going to your doctor and preparing for a visit. What is a typical patient going to get run? That’s kind of one of our funny lines that we say. A lot of times a patient will say “oh my doctor ran all these labs”. It’s a comprehensive metabolic panel, which it sounds to listeners, just the word comprehensive metabolic panel. Right, it sounds comprehensive? And it has all these different analytes, but it’s this a cheapo one panel. It looks a liver, kidney, electrolytes as you know. But what are like 5 or 6 labs that we’d want them to request from their physician?

J: Sure great question so I think it’s important to have those basic labs like the comprehensive labs, CBC to check just to make sure that there’s no overt issues going on in terms of there’s no significant kidney dysfunction, there’s no significant leukocytosis infection, I think it’s important to have those, but they’re very basic in the sense that they don’t give you much information. So a couple important labs that your regular doctor’s going to check is going to be a hemoglobin A1c which gives you a 3 week window of what your sugar usually runs and the way that works is you have these hemoglobin particles, when you have sugar in our bloodstream, it causes advanced glycolate endo products and you can measure that. That’s a good, kind of, start but it doesn’t give you as much information as you want. It’s not going to catch people who are prediabetic,necessarily, and so better tests that I would look at are insulin – so what is your insulin level so insulin is going to be a much earlier predictor of diabetes but also metabolic syndrome and so just for the listeners, basic concepts when you eat something that’s basically glucose dominant it goes into your system, glucose gets raised in your bloodstream and so insulin is the reponse to drive that glucose into your cells so if you’re having a lot of spikes of glucose your insulin level is going to start going up to counteract that.

Most primary care doctors are not going to check that. So having that is one of the more powerful tests you can look at to really say, “look your on the verge, your hemoglobin A1c may be normal but your insulin is high, so you may be going that direction.” Instead of waiting for the after effects when you already have it, let’s try to address it beforehand. So that would be one. The cholesterol that you mentioned, I would ask them to check an APOB to APOA1 ratio which is kind of what we talked about where your LDL may be elevated, but is it a good type of LDL or is it a bad type of LDL? That’s an important one that your doctor probably won’t check unless you ask them. Within that, the triglyceride level is one of the most important tests, so triglycerides, if they’re elevated, are going to be a reflection of elevated glucose in your system.

A: Right.

J: You can have some people who have genetic predisposition, familial type of triglyceridemia so those people are going to have high levels, but the majority of people will actually have, you know, levels that are relative to their carbohydrate intake. Another good one is going to be the MTHFR gene mutation, which I know you are probably pretty big on where people will not actually be able to methylate their vitamin B levels and so it won’t actually get the benefits of eating carbohydrates from that sense. What else? Then you can also get levels like we talked about earlier, the high res CRP level which is going to measure overall body inflammation. One of the ones that I really like people to get is a DEXA scan.

A: Ok.

J: So, I don’t know if we can just briefly talk about that, so DEXA scan basically is going to look at a couple things – we use it for osteoporosis measurements so we look at bone density but we also can use it to look at body fat percentage and the specific types of fat that we’re looking for so for listeners, there’s different types of fat there’s quite a bit of variance so there’s visceral fat which is going to cover your organs and that is the most metabolically active fat that we have. Then there’s going to be subcutaneous fat which is the fat that you’re going to see in the hips and thighs which is obviously not good but it’s not as metabolically active.

A: The pinchable stuff that doesn’t look as good.

J: Exactly but the visceral fat, and this usually ties into people who are skinny on the outside, have an essentially normal BMI, but that fat is so metabolically active, releasing so many inflammatory cytokines, damaging your blood vessels, that you want to see is that really the fat I want to get rid of, how much of that do I have? Just a caveat, the DEXA scan is not 10)% accurate, it is an estimate so you can’t just take it at its face value you have to do what you’re doing and repeat it and see if there’s any change specifically for what you’re looking at.

A: And the less expensive variant of the DEXA scan is some of these bioimpedance analysis machines out there and so we do, like, in body we do that at our practice and that has a 8 point of contact electrical impedance, but, yeah, as you’re stating, there’s variances especially with women that are cycling with fluid retention and so we like to look at consistency of measurements as far as time of the day, whether it’s pre or post bowel movement, things like that, to take into account any variances however, it is very helpful when looking at that pounds of dry, lean mass versus pounds of body fat mass and then the variances of distribution and that visceral fat scoring which we can see change by structured diet and we do see it correlating with reduced insulin resistance when we’re looking at the fasting glucose levels coming back into optimal range so it’s definitely a strong correlation there.

J: So that, yeah, part of it is how are you feeling? Obviously that’s the subjective but the objective is here is the hard data, here’s your labs, here’s what’s changed based on what we’re doing, here’s your DEXA or your Body Pod or your impedance, granted there’s some variation but the reason it’s important is because it goes back to this whole idea of using weight as the end all, be all marker of success, right? So if you go on a standard diet, you know, which inevitably they’re all the same – they’re all basically a calorie restrictive diet – what happens? You burn through your glycogen stores and glycogen holds on to water so glycogen is basically just the sugar in your muscle and your liver. Once you burn through that, you’re going to lose weight, you’re going to drop but it’s mostly water weight.

All those diets, if you maintain a calorie restriction less than 1000 calories for an extended period of time, you’re going to start having protein catabolism so you’re going to start breaking down your lean body mass so you might lose 20 pounds and feel very virtuous about it, but what have you lost? You lost 7 pounds of water, 5 pounds of lean body mass, and maybe some fat. And so, when you start going back to the way you were previously eating you do not have as much lean body mass to really burn that energy, which is what we want. So using a DEXA scan you can have a better idea of “ok, I lost 20 pounds but was it 5 pounds of lean body mass, which I don’t want or was it mostly visceral fat or subcutaneous fat?” So it also gives you a better idea of where the weight loss is coming from which is what we really want to know.

A: Absolutely and I think that’s the counterintuitive element and we talk about that plateau and frustrated is only so far away from the other “f- it” term when you’re dieting and losing weight and often when we hit that plateau because our basal metabolic weight dropped with our muscle loss, that’s where we tip into the frustrated world so for sure. Before we go on, I want to transition to talk about some tools and anything that you- kind of, your go-to and your repertoire for solving things like insulin resistance or if there’s any particular go-to supplementation or elements, but before we go into that I just want to let listeners know, with the launch of our Virtual Ketosis Program which is in active mode, so we’re not accepting new participants until January we do have, though, 2 weight loss blood panels that are on our site now, so there is a Weight Loss Plus and Weight Loss Basic Panel. I will put a link in the show notes, or Becki will probably put links in the show notes-

B: I sure will.

A: But the Weight Loss Plus includes the Comprehensive Metabolic Panel, it also looks at uric acid which is a marker to look at kidney function to look at protein and sometimes going higher protein diet can have influence there so we like to look at uric acid and gout risk and things like that, it does look at C reactive protein, homocysteine which is a marker of vascular inflammation it includes that hemoglobin A1c 3 month blood sugar average. It also includes the lipoprotein distribution using the Berkeley Cardiovascular Advanced Pale so that A:B ratio that we’re speaking of here, as well as a pretty thorough thyroid assessment so beyond just that TSH and your free T4 we’re looking at your Free T3 and your thyroid peroxidase so inflammation in the gland. Vitamin D and your baseline DHEA, so that’s our Weight Loss Plus Panel.

A great thing to have run and you can bring that into your physician or just use it as your own baseline data, and/or we can consult with you on interpretation of that information so we’ll put notes in the show notes and I think that covers most of the labs that we discussed as far as foundational data to jump into things. Ok. So let’s go onto tools so when we’re talking about monitoring – I love the idea, Dr. John, of using the DEXA scan and using variances beyond the scale to look comprehensively at what’s going on in lean mass and fat mass. How about if you’re dealing with someone who’s struggling with getting into ketosis, what are 2 or 3 tips or techniques and have you had people that just never get a positive – most people use urine strips to test their ketone production so what are your first troubleshooting techniques, I suppose?

J: Sure s- and it’s very important, what you just brought up, is we’re all different so we’re all going to approach it from a different perspective. Some people are going to have a much different experience so don’t compare yourself to your friend, or your husband or your neighbor because based on a lot of different variables, you’re going to have an easier or harder time getting into ketosis. For the people who really have a hard time getting into it no matter what their macros look lie, even if they’re doing 90% predominantly fat, I start off by asking what type of fat they’re consuming. So a pretty common mistake that a lot of people will make is they’ll use dairy as their primary source of fat so milk, cheese, even things like butter. Some people who have insulin resistance will actually have a very difficult time getting into ketosis using dairy fat as their primary fat source. And that’s because you can get some insulin effects from some of the proteins that are in those compounds.

So if that’s the case then I’ll tell them to consume more of a MCT based fat so using coconut oil or using, you know, things like MCT oil to try to really maximize the benefits of that because your body actually handles those oils much differently than other types of fats so maybe you need to change- triglycerides are basically going to be burned up in your system and they’re not going to acuse and y metabolic activation. The other thing that, if that doesn’t work or if people are still struggling, doing fasting is probably the best thing that you can do to really reverse all of those metabolic effects and so I’ll start saying- ok well I don’t like to start people off with a fast to start a program because I also want to get away from eating disorders, a lot of people have eating disorders based on their experience in the past so I don’t want this to be “ok yeah you’re going to do a ketogenic lifestyle, here’s what you do you don’t eat anything for 5 days.” It doesn’t go over very well. They say “ok yeah I’ll lose weight but I’ll also be starving.” But if they’ve tried multiple different things that I’ve recommended, then a 3-5 day fast is really going to push their body over the edge and usually will have a tremendous long-term impact. And I actually use fasts for myself. I’ll probably do a 5-7 day fast every 6-8 weeks for different reasons, more for MTOR reduction, things like that to make sure that I don’t have a significant amount of metabolic damage. Other things that you can use-

A: And can you – can you walk listeners through that because that’s pretty extreme sounding to some. Is this a water fast is this a bone broth fast, what type of fasting do you do for that 5 day period?

J: So it depends on whether or not you’ve done it before and how much you can handle. Obviously, the water fast would be the ultimate in terms of fasting. Most individuals who will do fasting will also just do it also for fat loss and you can anticipate, probably, half a pound of real fat loss per day by doing it. I usually will do either water fast or a bone broth fast and the bone broth fast, basically, you’re just trying to get the electrolytes, the collagen, things that are not going to raise your insulin level and so you basically still get the benefits of a fast, but it’s not as painful, basically, as a water fast.

I think it depends on which one you use I think most people will have an easier time doing a bone broth fast because they can consume something, it feels like nutrition, and so that psychological component “I’m not really starving myself, I’m just not eating full meals” is a lot easier and a lot of people will even do fat fasts where they’ll still do their bulletproof coffee in the morning which may or may not really raise your insulin levels so may or may not be effective. I think it depends on the individual so some people may do it and have a negative effect and other people really can’t do it. For me, it’s either bone broth fast or stric water fast because I’m trying to affect the mitochondria which I don’t want any negative effects on it by consuming any types of fats or macronutrients.

A: And then what about people that are of low body weight? I have a couple Wahl’s Warriors and people that are doing keto and are women, maybe, 5’4” 96 pounds, 97 pounds, you know, and so we’re constantly working to keep enough nourishment to not have that, of course, half pound fat loss per day when they’re fasting, what’s the cost-to-benefit ratio? I guess this is a truly selfish clinical question because I’ve been resistant to pushing this woman more than 24 hours and she has read Dr. Wahls does 3 days yada-yada and so what’s the cost-to-benefit ratio of someone who is of a lower body weight to get that mitochondrial effect so would you pre-load them or post-load them or what would you do for recovery to keep it as an ongoing fat fast or just do, like, an 18/6, what would be your approach?

J: Yeah that’s a really great question and I do have this experience with a lot of athelse. A lot of athletes that I work with, they’re 4% body fat they do not have the ability to do extended periods of fasting. For those people, you do not get as much benefit from, like, a mitochondrial cellular level but what I’ll do instead of a long-term fast, I generally will do, like a 24 hour fast or for a week I’ll tell them “Ok just eat dinner, don’t’ eat anything else throughout the day” and so you do get some of the benefits but you’re still not going to drop a significant amount of weight, right? So for those people, especially if you’re an athlete, you have to recover, you have to have that macronutrients and micronutrients or else you’re going to get more cellular damage than you want. It’s important not to do an extended period of fasting. Alternatives, you could pre-load them. I don’t think you get much benefit out of that-

A: Right.

J: Because your body is so smart, it’s going to utilize what it needs and get rid of the rest. So I think, in my experience, a 24 hour fast tends to work pretty well..

A: Ok.

B: Ok. And then in our protocol we use 3 days of intermittent fasting, kind of a 16/8, just restricted eating for the general public, do you include any intermittent fasting within you protocol, other than the prolonged?

J: Absolutely I think intermittent fasting is probably the most important component of any type of lifestyle, to be honest with you. I think for a number of reasons but from a biohacking standpoint, doing a 16/8 basically where you’re not eating past, I don’t know what time you use, but I generally will say “eat between 10 o’clock and like 6 o‘clock” or something like that so by 6pm you stop eating, so what does that do? So number 1) when you eat late at night, you actually get decreased growth hormone production. You have worsening sleep because your body is trying to digest that food.

So you negatively affect your sleep and when you negatively affect your sleep, in the morning you get significant cortisol defects, and raise insulin and it can raise your leptin and so that’s why I like biohacking so much, because it takes into account all these different variables which are all affecting your body very similarly and that is whether or not you are over stressing your body, overstressing your sympathetic nervous system which is going to cause you to basically have all these metabolic defects. So for a lot of people, that’s usually the intro is “ok here’s what we’re going to do we’re going to do intermittent fasting basically everyday” I mean, I will do it every day and then as people get more accustomed to it because it’s quite a fight for a lot of people to say “you’re only going to eat between these periods of time.” People have a hard time converting to that. Once they’ve converted, then I think it’s important to start incorporating the 24 hour fast and the 3-5 day fast, you know, kind of a gradual indoctrination, I guess is how I would look at it.

B: Sure and that makes it a little bit easier to-

A: Dip your toe in the water first.

J: Exactly.

B: Let’s talk about any particular supplements or Apps or other tools that you would use for getting best outcomes in ketosis and also for monitoring.

J: Ok. Yeah. So there’s a couple things that most people will use so you talked about the urine ketone strips, I can go either way on this I think for some people it’s important because initially it’s going to give them a positive reinforcement that they’re producing ketones. Eventually you get false negatives because your body’s actually using those ketones so they don’t show up in your urine so the test is negative. I really like the fingerstick blood prick and the breath test – I was going to talk about this at KetoCon but I didn’t have enough time -the blood ketone urine test going to check beta hydroxybutyrate or the breath ketone is going to check acetyl-CoA or the breakdown of acetyl coA or acetone. And that’s important because you want to know – so the blood one is really going to tell you if your body is making ketones but the breath one is going to tell you if you’re actually utilizing those ketones, right?

So when you have higher levels of acetone in your breath, that means your body is actually converting those ketones into the active form that you want to use. So I’ll sometimes use a ratio to show people that they’re producing them a lot but you’re not using them so you’re not quite fat adapted yet. And people have to understand that it takes a while once you converted to a ketogenic lifestyle to actually utilize the ketones that you’re producing. So step 1 is getting your body away from using sugar or glucose as the main fuel source. Step 2 is allowing your body to upregulate different types of receptors to be able to use those ketones as fuel.

Once you do that, then your body can actually – you can measure it and you can say “Ok I’m fat adapted.” So, obviously, ketones are very important for anybody that’s doing a ketogenic lifestyle. Other things that I use for myself and a lot of the biohackers is slepe. I think sleep is an incredibly important type of nutritional lifestyle. So I’ll use something like an Oura Ring which will measure my sleep patterns, you can use a FitBit or an Apple watch there’s a lot of different things on the market that you can use. I think it’s important to know if you’re’ sleeping and what type of sleeping you’re having, because that will positively or negatively effect if you’re able to be in ketosis or be functionally healthy.

A: Sure.

J: So those are, if I wanted to start with 2, those would be the first 2 that I would tell people to check.

A: And on the breath ketone meter, have you seen anything clinically with SIBO and false data as far as acetate?

J: Yeah, obviously, so you can get elevated levels with SIBO. I don’t have enough clients that I would say I work with that have SIBO to really be 100% accurate and in terms of different breath ketone meters, obviously there’s the Ketonics which, I think, has been out there longest, Level has come out with one, and they were at KetoCon and I’m interested in seeing more about their product. I think that- my hope is that as this becomes more mainstream, there’s going to be more technology that comes into it so you’re going to have more accurate data, cheaper data and so more people are going to be able to use it and that’s one of the downsides that a lot of people will say “well it’s expensive because I have to buy ketone strips or blood meter stirsp and each one is $2” and it becomes a cost-analysis benefit. So I think as Silicon Valley really starts pushing healthcare measurements, which they are right now, the cost is going to come down, more people will be able to utilize it and will get better outcomes.

A: Yeah absolutely and, again, it goes back to that individualized, what’s your base norm and what are other things that you can check in your body knowing you’re keto adapted as far as cognition, the feeling with you body a lot of people will state that they feel flatter in their abdomen in general and energy, sleep, all of those things, breath changes and then what’s your norm and then what score are you looking for versus, comparing to friends or other people that are tracking because there is this metabolic chemistry equation that is unique to the individual of how their body is going to adapt and perform.

J: Absolutely and then on that note, I would just say that people have to realize, and the reason I think a lot of us call it a ketogenic lifestyle is that have realistic goals. So don’t say “Ok I have to lose 50 pounds in 2 week and that’s going to be my marker of success.” This is something that if you’re going to do it, do it for a lifetime. This is really a way to be healthy so you don’t have to see physicians, you don’t have to be on multiple medications, and you’ll be able to enjoy the benefits of real nutrition again which I think a lot of people are missing.

A: I love that and even taking it within that mindset a step further, I think that often there’s this rigidity factor – it’s human nature, i think , when we want to do a diet or lifestyle change, what is the structure? What’s the plan? And so we have people now that are 4 weeks into our Virtual Keto Program and they’re like “So fasting feels really great can I do it a 4th day?” It’s like “Well yeah, you can do it every day” This is the start, this is what this feels like, now what does your body tell you? Or people will say “I’m not hungry, do I have to have 2 snacks?” “Well, listen to your body.” It’s interesting. Finding the dance in that rigidity that something with structure can also be very freeing because you remove a lot of anxiety and rumination of “is this right? Is this yielding results” and so having that structure can be helpful but then listening is important too.

J: Yeah exactly. I think, like you mentioned, everybody’s differents so you’re going to have a different response but a part of any type of nutrition that’s going to try to heal your body but the ketogenic lifestyle, specifically, is that you will start listening to your body again. Those signals that your body are giving you to tell you that you’re hungry those become normal again so you have a better sense of what’s going on. If you’re hungry, that’s great eat something. If you’re not hungry, you don’t have to eat. We have to get away from this concept that if you’re not fueling yourself 24/7, you’re going to somehow be unhealthy. Not at all. Your body is very very adapted to eating when you’re hungry and then when you’re not utilizing your fat stores for energy. It’s a beautiful symbiosis that we have.

A: Absolutely. And just finally for lisentiners, if we’re talking about – I think we did a good hit as far as foundational information, I guess for those that are talking to their doctor and they’re getting a backlash for those that aren’t open-minded to the concept, what’s your quick 30 second or 1 minute rebound to the question of kidney damage with the ketogenic diet and ketoacidosis? I think those are the 2 main pushbacks. What’s your answer and what does the patient use to advocate against those 2 things?

J: Sure and that’s a great question. So I’ll start with ketoacidosis because that’s probably the one that’s most common. So just for listeners, one of the biggest myths of ketosis is that if you do it, you’re going to be in ketoacidosis and I think it’s conceptually physicians don’t understand what the difference is, so there’s nutritional ketosis which will drive your ketone levels up, you know, to a maximum of about 5 depending on which scale you use, but 5. Diabetic ketoacidosis is a life threatening disease that people who do not have insulin will have and usually the ketone levels will be in the 15-20 range so it’s a very, very different metabolic dysfunction where you have very high glucose levels, very high ketone levels, and your body is unable to use the glucose as fuel and so it starts making these ketones form fatty acid breakdown and that drives your acid-base disequilibrium and you can die from it. When doctors hear or see ketones in the blood or in the urine, that’s what they think is happening and it’s really educating, I think it’s important to educate the population so that when they go to their doctor and they say, “I’m doing ketosis” or “I’m doing a ketogenic lifestyle.”

And the doctor says “Well you’re going to have diabetic ketoacidosis” they can almost educate the physician and say “there’s a difference between nutritional ketosis and diabetic ketoacidosis and here’s the difference-” So I actually have pamphlets for my clients that I give to them to give to their physicians so that there is a better understanding because I think the more healthcare professionals start understanding the basic differences, the better we’re going to be as a society. We’re going to have more doctors who are going to be pushing nutrition as a way to heal things versus being a barrier to what we’re trying to accomplish.

So I think it’s really getting the information out there, like we’re doing, like you’re doing, have these conversations, I see more celebrities doing it as they start pushing it, you know, we’re a celebrity driven society, as more people start talking about it, people are going to think it’s ok and start to ask their doctors. You know, same thing with kidney dysfunction, you know, I mean, that’s another myth that, I think, will be eventually debunked but it takes a while unfortunately. And I will actually talk to physicians os if I have clients that say “my physician doesn’t want to do these labs or is concerned about this.” I’ll say ‘Ok give them my number and I’ll send them all the reference articles they want so they can read about it.” And invitable it’s this light that comes on like “Ok I remember that but I don’t really remember that so let em look into it” And then they come back and say “Ok , you’re right there’s a difference.” And so it’s just spreading the information.

A: Sure and I think, like you said, at the end of the day, physicians get into the field to want to help people and everyone following that first “do no harm” mantra, it’s just our understanding of what “no harm” is and what you said, the doctor that’s chasing adding carbs to the diet to chase the insulin dosage or, you know, wanting the patient to stop a ketogenic diet because they’re worried about stopping their glucophage or metformin versus sunderating “ok you’re committed to this lifestyle, let’s reduce the medication and let’s let the body do the work.” It’s just a connection and I think that doctors are often inspired by successful outcomes from clients and want to work with the patient and if you’re getting, I think, too much push back and you’re doing all your work, then you might need to shop for a different physician.

J: RIght. Very true. Very true. And I think also, you know, the medical community, we’re taught to treat things. So we’re taught “here’s a disease, you have pneumonia this is how you recognize it, this is how you treat it.” We’re not very good at teaching “this is what we need to do to prevent diabetes.” So I think we need to have a shift and it’s starting in some medical schools where the shift has become “how do we prevent all these chronic diseases that we’re experiencing because as a nation, you know, we’re goin got go bankrupt with our medical healthcare based on our fact that we have so many people with chronic diseases that we’re keeping alive longer but they’re not healthy and so now we have a subsection of society that is so unhealthy, but will live longer, and cost tremendous amount of money for the society so how do you address that? If we can address that, then we don’t have to worry about repealing Obamacare or whatever they’re trying to do. We can address it and drive down the cost tremendously. There’s so many benefits from what we’re trying to accomplish.

A: Absolutely.

B: Yes and I think we’ve gotten so much good information in this episode, it’s already been an hour I can’t believe it. We’ll have to get you on for apart 2 because we still have so many questions, but I think we’ve gotten some good information just basics on ketosis how to work with your doctor, what labs to ask for, and, really, how to be an advocate for your own health.

J: Absolutely – it’s been a pleasure.

A: Thank you.

B: So in closing, what did you have to eat yesterday.

A: This is always – we have to ask. What’s your 24 hour recall?

J: Yesterday – let’s see- so yesterday I’m training for a triathlon, or like a half Ironman so my nutrition has been a little bit different but I did a – I call it a Keto Doctor Coffee but it’s basically like your Bullet coffee with a twist to it, I then exercised, went on a 10 mile run. I sometimes will do a post run fast so I didn’t eat all day and the reason I did that is to really drive my growth hormone production and then at night, I did pretty well, I did kind of a vegetable stir fry so I used – I get all my meats from a company up in Alaska that I know the meat quality is very good, so we did a lamb shank plus roasted vegetables smothered in MCT oil. And it was pretty phenomenal.

A: And what’s your twist on the- what’s your keto coffee twist?

J: Yeah so I try to avoid butter – and my thing I think – I have tested this, I have a significant insulin response to dairy so I try to avoid that, so I try not to use too much heavy cream or if I do, it’s very little bit I’ll use coconut milk instead, I’ll use ghee instead of butter because there’s not so much fo the milk products so I don’t get the casein so I don’t get that response and then I’ll use a little bit of espresso instead of coffee just to get that extra caffeine, which I need, because I have 3 little children so I have to keep up with them.

A: Awesome.

J: And then I’ll use the Dave Asprey brand Octane so it’s more specific- basically a type of MCT and I’m not a spokesman for Dave Asprey. Don’t take that as an endorsement.

A: Ok awesome. Ok so that’s your rocket fuel that gets you rockin’. Well awesome it’s been our pleasure to have you one the show, you can find more information on DrJohnLimanskymd.com so it’s going to be in our show notes and it’s just spelled like it sounds j-o-h-n-l-i-m-a-n-s-k-ymd.com. And we’ll put some show notes together for you guys including those lab panels that we discussed. As always, thanks for tuning in, if you have any questions after please put them in the AskAli box on the Podcast and we will look forward to learning more as things evolve in the conversation so thanks again, Dr. Limansky.

J: Thanks you guys it was a great time talking to you and it’s a great honor. I love what you guys are doing and keep it up.